HomeMy WebLinkAboutMiscellaneous - 410 BLUE RIDGE ROAD 4/30/2018 t oklrxPspsacnuserrsLlectical odeAu ndments527CMR12.00§Rule 8: in accordance-withthe-provisions of M.G.L.c.143,§,3L,the
permit application form to provide notice of installation of wiring shall be uniform throughout the Commonwealth,and applications shall be filed-
on the prescribed form.After a permit application has been accepted by an inspector of Wires appointed pursuant to M.01 c. 166,§32,an
electrical permit shall be issued to the person,firm or corporation stated on the permit application.Such entity shall be responsible for the
notification of completion of the work as required in M.G.L.c.143,§3L.
Permits shall-be limited as to the time o£ongoing construction.activity,and maybe,deemed-bythelnsp.ector_of_Wires abandoned-and-invalid,if,he_.
or she has determined that the authorized world has not commenced or has not progressed during the preceding 12-month period.Upon written
application,an extension of time for completion of work shall be permitted for reasonable cause.A permit shall be terminated upon the written
request of either the owner or the installing entity stated on the.permit application.
The Permit Extension Act was created by Section 173 of Chapter 240 of the Acts of 2010 and extended by Sections.74 and 75 of Chapter 238 of
the Acts of 2012.The purpose of this act is to promote j&growth and long-term economic recovery and the Permit Extension Act furthers this
purpose by establishing an automatic four-year extension to certain-permits and licenses concerning the use or development of real property.With
limited exceptions,the Act automatically extends,for four years beyond its otherwise applicable expiration date,any permit or approval that was
"in effect or existence"during the qualifying period beginning on August 15,20 Wand extending through August 15,2012.
tQlule 8—Permit/Date Closed: .' + 12 —/!,! ** Note•Reapply for new ermit
�ermit Extension Act—Permit(Date Closed: J — Z /
Date....f..!...Z3-e 9'
...................
1 N°RTM
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
SUSf
This certifies that ............. h� 4-( . ...............................
has permission to perform ............! T ..................................................
wiring in the building of.............(..'.!f.I.L�. ........................................
��`at..... � X. ......� Orth Andover,Mass.
Lic.No.�O/9 . ...............( .......
CSLECTRICAL INSPECTOR
Check #
0 ?�r7
Commonwealth of Massachusetts Official Use Only
Department of Fire Services Permit No. Z j 7
BOARD OF FIRE PREVENTION REGULATIONSOccupancy and Fee Checked
[Rev. 1/071 (leave blank
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code(MEC),527 CMR 12.00
(PLEASE PRINT WINK OR TYPE ALL INFORMATION) Date:
City or Town of: NORTH ANDOVER To the Ins p ctor Wires:
By this application the undersigned gives notice of his or herintention to perform the electrical work described below.
Location(Street&Number)_ 4/111
Owner or Tenant �� �� Telephone No.
Owner's Address
Is this permit in conjunction with a building permit? Yes No
❑ (Check Appropriate Boz)
Purpose of Building_S'j � � y Utility Authorization No.
Ezisting Service e7lelt Amps `ZU /ZS/p Volts rd Overhead ❑ Und
g ❑ No.of Meters
New Service Amps / Volts Overhead❑ rd Und
g ❑ No.of Meters
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work: ��� Gv
Sy 1�
Completion of the followin table may be waived by the Inspector of Wires.
No.of Recessed Luminaires No.of Ceil.-Susp.(Paddle)Fans No.of Total
Transformers KVA
No.of Luminaire Outlets No.of Hot Tubs Generators KVA
No.of Luminaires Z Swimming Pool Above ❑ In- ❑ o*
o mergency ig g
d. rnd. Battery Units
— . No,of Receptacle Outlets No.of Oil Burners FIRE ALARMS No of Zones
No.of Switches No.of Gas Burners No.of Detection and
Initiating Devices
No.of
Ranges No.of Air Cond. Tons No.of Alerting Devices
No.of Waste Disposers Heat Pump Number Tons KW No.of Self-Contained
Totals: -.............. Deteetion/Alertin ir Devices
No.of Dishwashers Space/Aren Heating KWLocal❑ Municipal
Connection ❑.Other
No.of Dryers Heating Appliances KW Security Systems:
No,of Water No.of No.of Devices or Equivalent
Heater Signs No.of Data Wiring:
Si s Ballasts. No.of Devices or Equivalent
r No.Hydromassage Bathtubs No.of Motors Total HP ITelecommunicaEons Wiring:
OTHER: No.of Devices or Equivalent
Attach additional detail if desired, or as required by the Inspector of Wires.
Estimated Value of Electrical Work: (When required by municipal policy.)
Work to Start: / 7p e' Inspections to be requested in accordance with MEC Rule 10,and upon completion.
INSURANCE COVERAGE: Unless waived b the owner, e
no
permit for the performance of electrical work may issue unless
the licensee provides proof of liability insurance including"completed operation"coverage or its substantial equivalent. The
undersigned certifies that such covers force,and has exhibited proof of same to the permit issuing office.
CHECK ONE: INSURANCE BOND ❑ OTHER ❑ (Specify:)
I certify,under the pains and penalties of perjury, that the information on this application is true and complete:
FIRM NAME: LIC.NO.: p7Z
Licensee: _ �L,�y� C�jl � Signature LIC.NO.:
(If applicable, enter"exempt"in the license number line)
Address: a SC �( Bus.TeL No.:
*Per M.G.L c. 147,s.57-61,security work re uires Alt.Tel.No.:
q Department of Public Safety"S"License: Lic.No.
OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally
required by law. By my signature below,I hereby waive this I am the requirement. check one
Owner/Agent ( ) ❑owner ❑owner's agent.
Signature Telephone No. PERMIT FEE: $
.n
� t .�, ,.
� � ��
�� l �0
. �
9
The Commonwealth of Massachusetts
LX Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, A"-02111
www.massgov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Leeibly
Name (Business/Organization/Individual):
Address: ,5'D t. i�e �j,,
City/State/Zip:l? &,cow, 1W, 0/6F:j�d Phone#:
Are you an employer? Check the appropriate bog: Type of project(required):
1.❑ I am a employer with 4. ❑ I am a general contractor and I 6. E]New construction
employees(full and/or part-time).* have hired the sub-contractors
2. n a sole proprietor or partner- listed on the attached sheet 1 7• ❑ Remodeling
ship and have no employees These sub-contractors have 8. ❑ Demolition
working for me in any capacity. workers' comp. insurance. 9. ❑ Building addition
[No workers' comp. insurance 5. ❑ We are a corporation and its
required.] officers have exercised their 10.❑ Electrical repairs or additions
3.0 1 am a homeowner doing all work right of exemption per MGL 11.❑ Plumbing repairs or additions
myself. [No workers' comp. c. 152, §1(4),and we have no 12.❑ Roof repairs
insurance required.] t employees. No workers' 13.0 Other
comp. insurance required.]
applicant,that checks box 41 must also f1;out the section below showing their workers'compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
$Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp,policy information.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name:
Policy#or Self-ins. Lic.#: Expiration Date:
Job Site Address: City/State/Zip:
Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
" firir up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct
Simature: Date: o
Phone#:
Official use only. Do not write in this area,to be completed by city or town official
City or Town: Permit/License#
Issuing Authority(circle one):
1.Board of Health 2. Building Department 3.City/Town Clerk 4. Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#•
Information and Instructions a
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute,an employee is defined as "...every person in the service of another under any contract of hire,
express or implied, oral or written."
An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more
of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the
receiver or trustee of an individual,partnership, association or other legal entity,employing employees. However the
owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the
dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
MGL chapter 152, §25C(6)also states that"every state or local Iicensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required."
Additionally, MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if
necessary,supply sub-contractor(s)name(s), address(es)and phone number(s)along with their certificate(s)of
insurance. Limited Liability Companies(LLC)or Limited Liability.Partnerships(LLP)with no employees other than the
members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have
employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial
Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should '
be returned to the city or town that the application for the permit or license is being requested, not the Department of
Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers'
compensation policy,please call the Department at the number listed below. Self-insured companies should enter their
self-insurageeTicense number on the appropriate line.
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant
that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current
policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city br
town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each j '
year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture ,
(i.e.a dog license or permit to bum leaves etc.)said person is NOT required to complete this affidavit.
The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions,
please do not hesitate to give us a call
The Department's address,telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents.
Office of Investigations
600 Washington,Street
Boston,MA. 02111
Tel. 4 617-7274400 ext 406 or 1-877-1-ASSAFE
Revised 5-26-05 Fax 4 617-727-7749
vnA,w-mass.govfdia
Date
R7M'�o TOWN OF NORTH DOVER
F PERMIT/FO LUMBING
♦ o • i
,SSACHUS�
This certifies that . .l�!�. . .�� �. ��" G�. . . . . . . . . . . . . . . . . .
has permission to perform . . ., �k. . . . . . . . .. . . . . . . . . . . . . . . . . . .
r
plumbing in the buildings of of .11-/A . . . . . . . . . . . . . . . . . . . . . . . . . . . .
' G 9.
at . . . . e-r. .0. ! .AS -. . . . . . . . . . . . , North Andover, Mass.
Fee. /�. . . .Lic. No.. . ).�d �! . ...-�... . . . . . . . . .
�r PLUMBING INSPECTOR
Check � >
630
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING
(Type or Print)
NORTH ANDOVER,MASSACHUSETTS f
f Date
Building Location �l �v e �� cJc �( D Permit# �,�
Owner O
R./ 14 ` Amount
New Renovation Replacement Plans Submitted Yes No
FIXTURES
6 .
suga C
>a�glv>avr
M FLOOR
24D FLOOR
3R11 FLOOR
41S FLOOR
SIH NJ"
siHFLOOR
71H IIDOR
gm H7.DOR
(Print or type) Check one: Certificate
Installing Company Name Corp.
Address -S `� �� P
Business Telephone 11 Z Firm/Co.
Name of Licensed Plumber: r l l Q /'o ✓�
Insurance Coverase: Indicate theype
of insurance coverage by c king the appropriate box:
Liability insurance policy Other type of indemnity Bond ❑
Insurance Waiver: L the undersigned,have been made aware that the licensee of this application does not have any one of the above
three insurance
Signature Owner Agent rl
I hereby certify that all of the details and information I have submitted(or entered)in above application are true and accurate to the
best of my knowledge and that all plumbing work and installations Wkionned under Permit Issued for this application will be in
compliance with all pertinent provisions of the MassachusSte 1 g Code and Chapter 142 of the General Laws.
By rgna e or Licensca.1-1
�Lme of-Aanbing L;Ce
Title
City/Town r3censeSer Master d Joumeyman
APPROVED toFncE usE oNLY El
r
I
.. `
-` The Commonwealth of Massachusetts
,r Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
www.mass.govldia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/P u
I tubers
Applicant Information Please Print Legibly
Name (Business/Organization/ln(lividual): 9 ^ `r b F
Address:
City/State/Zip: Phone
Are you an employer? Check the appropriate bog: Type of project(required):
1.❑ I am a employer with 0 4. ❑ I am a general contractor and I 6. ❑ New construction
employees(full and/or part-time).* have hired the sub-contractors
2.❑ I am a sole proprietor or partner- listed on the attached sheet.t 7• ❑ Remodeling
ship and have no employees These sub-contractors have 8. ❑ Demolition
working for me in any capacity. workers' comp. insurance. 9. ❑ Building addition
[No workers' comp. insurance 5. ❑ We are a corporation and its 10.❑
Electrical re
required.] officers have exercised their pairs or additions
3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑ Plumbing repairs or additions
myself. [No workers' comp. c. 152, §l(4),and we have no 12.❑ Roof repairs
insurance required.] t employees. No workers' 13.❑ Other
comp. insurance required.]
*A.........T'.......a 1. 1. ... ..s..1.... -
�...;applicant,that c„ecks„o; 1 ..:,:� --sofill Il out the section below showing their workers'compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
:Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name: Fcv-..^ cc
-7 s
Policy#or Self-ins. Lic. 6 —C_ Expiration Date: ® -
Job Site Address:_q1 e— r City/State/Zip:
Attach a copy of the workers' compensation oticy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
Ido hereby cl under th pains and penalties of perjury that the information provided above,is true and correct
Signafore: Date: ` �U
Phone#:
Official use only. Do not write in this area,to be completed by city or town official
City or Town: Permit/License#
Issuing Authority(circle one):
1.Board of Health 2. Building Department 3.City/Town Clerk 4. Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire,
express or implied,oral or written."
An employer is defined as"an individual,partnership,association, corporation or other legal entity,or any two or more
of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the
receiver or trustee of an individual,partnership,association or other legal entity, employing employees. However the
owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the
dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required."
Additionally, MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if i
necessary,supply sub-contractors)name(s), address(es)and phone number(s)along with their certificate(s)of
insurance. Limited Liability Companies(LLC)or Limited Liability.Partnerships(LLP)with no employees other than the
members or partners,are not required to cant'workers' compensation insurance. If an LLC or LLP does have
employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial
Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should
be returned to the city or town that the application for the permit or license is being requested,not the Department of
Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers'
compensation policy,please call the Department at the number listed below. Self-insured companies should enter their
self-insurance license number on the appropriate line.
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant
that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current
policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or
town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each
year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
(i.e.a dog license or permit to bum leaves etc.)said person is NOT required to complete this affidavit.
The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions,
please do not hesitate to give us`a call
The Department's address,telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 0.2111
Tel. 4 617-7274900 ext 406 or 1-877-M-ASSAFE
Fax# 617-72.7-7749
Revised 5-26-OS www.mass.g.ov/dia
Date...V,*51....
ORTPI
4,0,
TOWN OF NORTH ANDOVER
0
PERMIT FOR WIRING
.S$AcmUS
This certifies that ....... ......... .......................................
has permission to perform ...... ............ ...............
...t`. {............ ..........l
. ........................
wiring in the building of.....k!?.zn,......... .......................
/"/C( ' ,
a ..... ........
.........iq.................Lf� .f ...... North Andover,Mas'0!.. odoN . . . ... ..... /... . .Fee. ........ X '�/
'
1% ELECTRICAL INSPECTOR
Check # 33K
Commonwealth of Massachusetts official Use Only (�
i..........:.: �/
Department of Fire Services Pernut No.
Occupancy and Fee Checked
BOARD OF FIRE PREVENTION REGULATIONS Rev. ]1/99
leave blatrl:)
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
AI l work to be performed in accordance with the Massachusetts Electrical Code(MEC).527 CMR 12.00
(PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: ��D 3
City or Town of: Al �n DDUG/2 To the Inspector of Wires:
By this application the undersigne gives notice of his or her intention to perform the electrical work described below.
Location(Street& Number) t�/U / ��,e! Q�� 11M
Owner or Tenant l2�GC/Z yyJ,e'� �L fly T Telephone No.
Owner's Address
Is this permit in conjunction with a building permit? Yes ❑ No ❑ (Check Appropriate Box)
Purpose of Building Utility Authorization No.
Existing Service Amps / Volts Overhead ❑ Undgrd❑ No. of Meters
New Service _ __ Amps / Volts Overhead❑ Undgrd ❑ No. of Meters
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work:
Com)lelion o 'the following table may be waived ht,the Inspector of IVirec.
No. of Recessed Fixtures No.of Ceil.-Susp. (Paddle)Fans No.of Total
Transformers KVA
No.of Lighting Outlets No.of Hot Tubs Generators KVA
No.of Lighting Fixtures Swimming Pool Above ❑ In- Elo.o mergency Lighting
rnd. rnd. Battery Units
No. of Receptacle Outlets No.of Oil Burners �F1RE ALARMS No.of Zones
No.of Switches No.of Gas Burners 11No.of Detection and
Initiating Devices
No.of Ranges No.of Air Cond. Total No. of Alerting Devices
Tons
No.of Waste Disposers Heat Pump Number Tons KW No.of Self-Contained
Totals: Detection/Alerting Devices
No.of Dishwashers Space/Area Heating KW Local ❑ Municipal ❑ Other
Connection
No. of Dryers Heating Appliances Key Security Systems:
No.of Devices or Equivalent
No. of Water KW No.o No.o Data Wiring:
Heaters Signs Ballasts No.of Devices or Equivalent
No. Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring:
No.of Devices or Equivalent
OTH FR:
Attach additional detail it desired,or as required by the Inspector o/'Wires.
INSURANCE COVERAGE: Unless waived by the owner,no permit for the performance of electrical work may issue unless
the licensee provides proof of liability insurance including"completed operation"coverage or its substantial equivalent. The
undersigned certifies that such coverage is in force,and has exhibited proof of same to the permit issuing office.
CHECK ONE: INSURANCE/ BOND ❑ OTHER ❑ (Specify:) 20,!5) 7",
,",
(Expiration Date)
Estimated Value ofElectricalWork: (When required by municipal policy.)
Work to Start: 4A- D='7� Inspections to be requested in accordance with MEC Rule 10,and upon completion.
I certify, under the paids and penalties of perjury,that the information on this application is true and complete.
FIRM NAME: f L L- — L [ 2l L. LIC. NO.:-,?/
Licensee:
1'TN,-)l'► E/ / _ (=L /)4 //q Signature LIC. NO.:
(Ifapplicabl mer "exe i"ilz the licensenumber line.) Bus.Tel. No.:O ��
Address: 6J- � Ox 4 ,c4 14 0 HE4111 S f2 (26 M I,� 0/X, --Tel.No.: JQ
OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally
required by law. By my signature below, I hereby waive this requirement. I am the(check one)❑ owner ❑ owner's agent.
Owner/Agent PERMIT FEE: $
Signature Telephone No.